The Cheshire East Council Scrutiny Committee met to discuss suicide prevention and mental health support, a domestic homicide review, an adult safeguarding review, and a proposal to streamline the process for determining substantial developments or variations of service. The committee agreed to delegate authority to the Statutory Scrutiny Officer, in consultation with the Chair and Vice Chair of the Scrutiny Committee, to decide whether a proposal represents a substantial change.

Suicide Prevention and Mental Health Community Support

The committee reviewed a report on suicide prevention and mental health support services available in Cheshire East, including support for families impacted by mental health issues. The report detailed the work of the Self-Harm and Suicide Prevention Board and the Mental Health Partnership Board, both of which report to the Health and Wellbeing Board.

Key services and information sources for residents were highlighted in the report, with a focus on support for carers, children, and families. The report also referenced a Mental Health Spotlight Review report focused upon children and families that went to the Children and Families Committee in November 2023.

The report noted that while support services are available, mental ill health, self-harm, and suicide remain concerns, and service capacity continues to be an issue.

Domestic Homicide Review: EMMA

The committee considered a report on the Domestic Homicide Review (DHR) following the suicide of Emma in September 2021. The review was commissioned by the Safer Cheshire East Partnership in April 2022.

The purpose of the DHR was to identify lessons learned from the case regarding how local professionals and organisations worked individually and together to safeguard victims. The review made several multi-agency recommendations, including:

• Training for officers focused on recognising indicators of coercion and control.
• Providing staff access to the review to facilitate their responses and raise awareness of coercion.
• Establishing protocols and resources to support responses to self-harm or suicidal thoughts in individuals experiencing domestic abuse.
• Identifying familial suicide as a risk factor for self-harm and suicide and sharing information with appropriate partners.

The report noted that the Safer Cheshire East Partnership seeks assurances from partner agencies about their responses to the learning from DHRs and oversees action plans. Actions already taken include training for partner professionals on the suicide timeline, engagement with victims of domestic abuse, and the introduction of suicide prevention training for council staff.

The report included quotes from Emma's family and friends, such as:

Our Emma was bubbly and confident and always there for everyone.

The report also noted that Emma's childhood was unstable due to her dad's heroin addiction and his domestic abuse towards her mum. Despite the abuse, Emma defended and loved her dad, and viewed the experiences as the norm.

The review highlighted that coercion and control is referenced in Part 6 of the Domestic Abuse Act 2021, emphasising the need for agencies to be aware of this as domestic abuse.

Adult Safeguarding Review - BELLA

The committee reviewed a report regarding the Safeguarding Adults Review (SAR) concerning BELLA, a 26-year-old woman diagnosed with autism in 2017, who experienced life-changing injuries after being hit by a train in January 2024. The purpose of the SAR was to identify lessons for multi-agency working to enhance future safeguarding practice.

The review highlighted several key areas:

• Transitions between Care Settings: The review found that communication was not always robust or undertaken across agencies during transitions between Emergency Departments, Mental Health Units, Acute Medical Wards, and private Mental Health facilities.
• Multi-Agency Communication and Coordination: The review found poor coordination and a lack of joint discharge planning, with no single point of oversight despite multiple agencies being involved.
• Mental Health and Autism Care: The review found that Bella's autism and trauma history were not consistently considered in care planning, and interventions often focused on 'behavioural' presentations, missing underlying mental health distress and trauma responses.
• Safeguarding Practices and Risk Management: The review found that risk and mental capacity assessments were inconsistently applied or recorded.
• Fluctuating Capacity and Professional Assumption-Checking: The review found that practitioners at times viewed Bella's risk-taking as 'lifestyle choice' without robust analysis of her capacity at the time.
• Family Inclusion and the Power of Lived Experience: The review found that Bella and her mother described a sense of being unheard and invisible within the system.

The SAR made several recommendations, including:

• Embedding professional curiosity and assumption-checking into safeguarding policies, supervision, and audit.
• Implementing a specialist autism and trauma-informed care framework and training staff across agencies.
• Mandating multi-agency discharge plan assessments for high-risk cases, with shared templates and expectations.
• Ensuring all high-risk safeguarding referrals include explicit consideration of sexual and criminal exploitation risks.
• Including the voice of individuals and families in all decision-making and explicitly recording how this has influenced outcomes.

The report included a quote from Bella:

The only people who really listened to me in hospital were the security guards.

Substantial Development or Variation of Service (SDV) - Stage 1 Process

The committee considered a report seeking their views on streamlining the process for determining Substantial Developments or Variation of Service (SDV). The NHS Cheshire and Merseyside Integrated Care Board (ICB) is reviewing numerous policies that may or may not impact residents of Cheshire East, and has a duty to engage with Local Authority Health and Overview Scrutiny Committees (HOSC) to seek confirmation as to whether the HOSC believes a proposal is a substantial change to NHS services.

To help deal with the SDVs in a timely manner, the committee were asked to consider streamlining 'Stage 1' (initial consultation phase) of the process, and agreed to delegate authority to the Statutory Scrutiny Officer, in consultation with the Chair and Vice Chair of the Scrutiny Committee, to decide whether a proposal represents a substantial change. The Statutory Scrutiny Officer, Chair, and Vice Chair may still decide convene the full committee to make this decision when deemed appropriate, and will report their decision back to the committee at the next available meeting, providing their reasoning for the determination of proposals as substantial, or not substantial.

The Cheshire and Merseyside Joint Health Scrutiny Arrangements Protocol was attached to the report.